Basic Information
| Provider Information | |||||||||
| NPI: | 1295741338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4177 FASHION SQUARE BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486035216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897919100 | ||||||||
| FaxNumber: | 9897916746 | ||||||||
| Practice Location | |||||||||
| Address1: | 4177 FASHION SQUARE BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486035216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897919100 | ||||||||
| FaxNumber: | 9897916746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301053500 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | 4301053500 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 3170069 | 05 | MI | MEDICAID |